The assistant coroner for the area of Manchester North has recently issued a Report to Prevent Future Deaths to the Northern Care Alliance NHS Trust in relation to a failure in systems which resulted in a delay in diagnosis and treatment for a cancer patient who subsequently passed away. The trust concerned provides a range of healthcare services including at Salford Royal, The Royal Oldham Hospital, Fairfield General Hospital in Bury and Rochdale Infirmary.

Mr Matthew Cox opened and concluded an inquest into the death of Mrs Monica McCormick who died in May 2020 aged 79. In October 2019 Mrs McCormick had been referred for a CT scan due to suffering from abdominal pain. The CT scan identified a perforation of the colon and there were concerns about the presence of a tumour. Mrs McCormick was transferred for surgery to North Manchester General Hospital where she underwent an extensive procedure involving an emergency laparotomy, sigmoid colectomy and end colostomy. During this process, tissue samples were taken and sent for testing due to the suspicion of a tumour. The pathology specimens were reported as showing a moderately differentiated adenocarcinoma – a tumour originating in the glands which is not at the most aggressive extreme. This report was not communicated to Mrs McCormick or her GP so she was unaware of the diagnosis of the tumour. She was scheduled for follow up after her discharge post surgery but on four successive occasions between December 2019 and March 2020 her appointment was cancelled by the hopsital. She remained unaware of her diagnosis.

It was only in April 2020 that one of the colorectal consultants reviewed Mrs McCormick’s case and noted the results of the pathology specimen and that nothing had happened since the report had been produced. Mrs McCormick was notified and follow up CT imaging arranged which showed a significant spread of the cancer. By the time this was identified, Mrs McCormick’s condition was deteriorating and there were no realistic treatment options for her. She passed away a few weeks later.

The coroner was concerned as to the trust’s complete failure to react to the pathology report and his finding from the available evidence was that had action been taken in October 2019, Mrs McCormick would have been well enough to undergo adjuvant chemotherapy which would at the least have extended her life by slowing the progression of her cancer.

In his report, the coroner stated that he was afraid that future deaths would occur unless action was taken, given the facts of this case. He detailed the matters of concern as follows:

  • the pathology sample was not followed up because, despite labelling the specimen to include the word ‘malignancy’, the operating clinicians sending the sample to be tested did not complete an online ‘suspected cancer upgrade form’ at the time of surgery;
  • appropriate consideration was not given to Mrs McCormick’s medical records at the time of her discharge from hospital, missing an opportunity to identify and rectify the error;
  • the pathology report was not sent to her GP when she was discharged from hospital;
  • appropriate consideration was not given to her medical records at the time that each outpatient appointment was cancelled.

The coroner therefore has required the trust to take steps to prevent the same thing happening to other patients given his view that Mrs McCormick would not have died when she did had the pathology report been appropriately considered and actioned.

Philippa Luscombe, who leads the specialist oncology and cancer claims team at Penningtons Manches Copper, comments: “A significant percentage of the cases that we deal with involving a delay in diagnosis and treatment of cancer are as a result of some very basic failings in care such as failures to follow up on test results and/or further investigations that are recommended. We have acted on a number of cases like Mrs McCormick’s where diagnosis and treatment have been delayed and the patient has passed away not long after the diagnosis has finally been made, with it being too late for treatment and the patient and their family having very little time to come to terms with the diagnosis.

“In our experience, there is often no inquest as the death in itself is not unexpected given the patient’s condition by that stage. In this case it is clear that the coroner was concerned that not only were the correct steps not taken when sending the pathology sample for testing but that there were then repeated failures to review Mrs McCormick’s records and realise that the pathology report needed action. His verdict was clear that these failures lost her the chance of treatment which would have prolonged her life.

“This is exactly the sort of situation where a coroner can use a Report for Prevention of Future Deaths to try to achieve exactly that – prevention of future deaths due to similar failings. Here the trust did not have appropriate systems in place to prevent a patient who was having tissue samples taken for testing for malignancy going six months without those results being considered and actioned. It will be for the trust to report back to the coroner as to what it has done to improve its systems but we hope that steps will be taken so that the situation cannot happen again. This is one of the real benefits of the coroner system – that a coroner can ensure that lessons are learned and changes are made.”